EFFECTS OF COMPUTER-BASED CLINICAL DECISION-SUPPORT SYSTEMS ON PHYSICIAN PERFORMANCE AND PATIENT OUTCOMES - A SYSTEMATIC REVIEW

Context.-Many computer software developers and vendors claim that thei r systems can directly improve clinical decisions. As for other health care interventions, such claims should be based on careful trials tha t assess their effects on clinical performance and, preferably, patien t outcomes. Objective.-To systematically review controlled clinical tr ials assessing the effects of computer-based clinical decision support systems (CDSSs) on physician performance and patient outcomes. Data S ources.-We updated earlier reviews covering 1974 to 1992 by searching the MEDLINE, EMBASE, INSPEC, SCISEARCH, and the Cochrane Library bibli ographic databases from 1992 to March 1998. Reference lists and confer ence proceedings were reviewed and evaluators of CDSSs were contacted. Study Selection.-Studies were included if they involved the use of a CDSS in a clinical setting by a health care practitioner and assessed the effects of the system prospectively with a concurrent control. Dat a Extraction.-The validity of each relevant study (scored from 0-10) w as evaluated in duplicate. Data on setting, subjects, computer systems , and outcomes were abstracted and a power analysis was done on studie s with negative findings. Data Synthesis.-A total of 68 controlled tri als met our criteria, 40 of which were published since 1992, Quality s cores ranged from 2 to 10, with more recent trials rating higher (mean , 7.7) than earlier studies (mean, 6.4) (P<.001), Effects on physician performance were assessed in 65 studies and 43 found a benefit (66%). These included 9 of 15 studies on drug dosing systems, 1 of 5 studies on diagnostic aids, 14 of 19 preventive care systems, and 19 of 26 st udies evaluating CDSSs for other medical care. Six of 14 studies asses sing patient outcomes found a benefit. Of the remaining 8 studies, onl y 3 had a power of greater than 80% to detect a clinically important e ffect. Conclusions.-Published studies of CDSSs are increasing rapidly, and their quality is improving. The CDSSs can enhance clinical perfor mance for drug dosing, preventive care, and other aspects of medical c are, but not convincingly for diagnosis. The effects of CDSSs on patie nt outcomes have been insufficiently studied.